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Purpose: Preventing fragility fractures by treating osteoporosis may reduce disability and mortality worldwide. Algorithms combining clinical risk factors with bone mineral density have been developed to better estimate fracture risk and possible treatment thresholds. This systematic review supported panel members of the Italian Fragility Fracture Guidelines in recommending the use of best-performant tool. The clinical performance of the three most used fracture risk assessment tools (DeFRA, FRAX, and FRA-HS) was assessed in at-risk patients. Methods: PubMed, Embase, and Cochrane Library were searched till December 2020 for studies investigating risk assessment tools for predicting major osteoporotic or hip fractures in patients with osteoporosis or fragility fractures. Sensitivity (Sn), specificity (Sp), and areas under the curve (AUCs) were evaluated for all tools at different thresholds. Quality assessment was performed using the Quality Assessment of Diagnostic Accuracy Studies-2; certainty of evidence (CoE) was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach. Results: Forty-three articles were considered (40, 1, and 2 for FRAX, FRA-HS, and DeFRA, respectively), with the CoE ranging from very low to high quality. A reduction of Sn and increase of Sp for major osteoporotic fractures were observed among women and the entire population with cut-off augmentation. No significant differences were found on comparing FRAX to DeFRA in women (AUC 59–88% vs. 74%) and diabetics (AUC 73% vs. 89%). FRAX demonstrated non-significantly better discriminatory power than FRA-HS among men. Conclusion: The task force formulated appropriate recommendations on the use of any fracture risk assessment tools in patients with or at risk of fragility fractures, since no statistically significant differences emerged across different prediction tools.

Purpose: Since vertebral fragility fractures (VFFs) might increase the risk of subsequent fractures, we evaluated the incidence rate and the refracture risk of subsequent vertebral and non-vertebral fragility fractures (nVFFs) in untreated patients with a previous VFF. Methods: We systematically searched PubMed, Embase, and Cochrane Library up to February 2022 for randomized clinical trials (RCTs) that analyzed the occurrence of subsequent fractures in untreated patients with prior VFFs. Two authors independently extracted data and appraised the risk of bias in the selected studies. Primary outcomes were subsequent VFFs, while secondary outcomes were further nVFFs. The outcome of refracture within ≥ 2 years after the index fracture was measured as (i) rate, expressed per 100 person-years (PYs), and (ii) risk, expressed in percentage. Results: Forty RCTs met our inclusion criteria, ranging from medium to high quality. Among untreated patients with prior VFFs, the rate of subsequent VFFs and nVFFs was 12 [95% confidence interval (CI) 9–16] and 6 (95% CI 5–8%) per 100 PYs, respectively. The higher the number of previous VFFs, the higher the incidence. Moreover, the risk of VFFs and nVFFs increased within 2 (16.6% and 8%) and 4 years (35.1% and 17.4%) based on the index VFF. Conclusion: The highest risk of subsequent VFFs or nVFFs was already detected within 2 years following the initial VFF. Thus, prompt interventions should be designed to improve the detection and treatment of VFFs, aiming to reduce the risk of future FFs and properly implement secondary preventive measures.

With increasing life expectancy, fragility fractures of the pelvic ring (FFP) are becoming frequent. In elderly, osteoporosis leads to a decrease of bone strength and resistance to the ligament’s traction; this represents the most important difference between FFP and fractures in young patients. Usually, these fractures are underestimated and treatment is often conservative. To evaluate clinical and surgical outcomes of surgically treated patients with FFP. We retrospectively enrolled 14 patients, in our Trauma Center, underwent surgery procedures for FFP between 2012 and 2014. All patients attended clinical and radiological investigation at 1, 3, and 6 months postoperatively and every year after surgery with a mean follow-up of 22 months. At 6-month follow-up, 11 patients resulted asymptomatic: able to maintain standing position and walk without crunches. Two patients were able to walk with one crunch. The patient with history of previous acetabular fracture walks with two crunches and is still waiting for total hip arthroplasty. The compromised health status and the diminished bone-healing capacity, in elderly, decrease chances for a good clinical outcome. In literature, many authors suggest that mortality rate in patients with FFP is similar to those with hip fracture. Diagnosis of FFP is very important: these fractures are highly disabling in elderly and can lead to displacement and instability. For these reasons, correct diagnosis and well-conduct preoperative plan are necessary to improve stability of fractures and support bone healing. After diagnosis, an anti-osteoporotic treatment is indicated to improve bone quality and bone healing. Our study shows encouraging results and demonstrates that minimally or less invasive osteosynthesis technique could lead to good outcome in these patients.

Osteoporosis is a common disease in elderly, characterized by poor bone quality as a result of alterations affecting trabecular bone. However, recent studies have described also an important role of alterations of cortical bone in the physiopathology of osteoporosis. Although dual-energy X-ray absorptiometry (DXA) is a valid method to assess bone mineral density, in the presence of comorbidities real bone fragility is unable to be evaluated. The number of hip fractures is rising, especially in people over 85 years old. The aim is to evaluate an alternative method so that it can indicate fracture risk, independent of bone mineral density (BMD). Femoral cortical index (FCI) assesses cortical bone stock using femur X-ray. A retrospective study has been conducted on 152 patients with hip fragility fractures. FCI has been calculated on fractured femur and on the opposite side. The presence of comorbidities, osteoporosis risk factors, vitamin D levels, and BMD have been analyzed for each patient. Average values of FCI have been 0.42 for fractured femurs and 0.48 at the opposite side with a statistically significant difference (p= 0.002). Patients with severe hypovitaminosis D had a minor FCI compared to those with moderate deficiency (0.41 vs. 0.46, p< 0.011). 42 patients (27.6 %) with osteopenic or normal BMD have presented low values of FCI. A significant correlation among low values of FCI, comorbidities, severe hypovitaminosis D. and BMD in patients with hip fractures has been found. FCI could be a useful tool to evaluate bone fragility and to predict fracture risk even in the normal and osteopenic BMD patients.

Aim of this study was to evaluate the cancellous bone quality of postmenopausal women (age >60 years) by diffusion tensor imaging (DTI) using mean diffusivity (MD) and fractional anisotropy (FA) in combination with proton magnetic resonance spectroscopy (1H-MRS). 20 postmenopausal women older than 60 years were introduced to dual-energy X-ray absorptiometry (DXA) examination in femoral neck and to an MRI spectroscopy and DTI evaluation at 3T. We observed that fat fraction (FF) can discriminate healthy and osteoporotic patients. Water mean diffusivity (MD) and FA can discriminate the healthy group from osteopenic and osteoporotic group. MD/FF vs FA/FF graph extracted from the femoral neck identifies all healthy individuals, according to DXA results. DTI and spectroscopy protocol performed in the femoral neck could be highly sensitive and specific in identifying healthy subjects.

Excess of bone remodeling is still the major pathogenic factor in involutional osteoporosis. This phenomenon is linked to an imbalance between neoformation (by osteoblasts) and resorption (by osteoclasts). Recently, research in drug development is focused on new and more “physiological” approach to balance bone remodeling. The efficacy of denosumab was proved in the prevention of vertebral and non-vertebral fractures and related to the ability of the drug to penetrate in cortical and trabecular bone. Recently, data from several clinical studies confirm that denosumab improves fracture outcomes, also at skeletal sites rich in cortical bone.

Bone is a tissue that dynamically adapts mass and architecture to the mechanical loads that occur in daily life in a world with gravity. Bone architecture and mass are influenced by the applied tension peak, whereas the bone formation rate is modulated by the stimulus frequency. In bone tissue, osteocytes govern the detection of mechanical afferents and their transformation into biochemical messages, therefore these cells can be considered a mechanosensor that directs osteogenesis to where it is most needed to increase bone strength. The stimulation of osteocytes occurs with several modalities: shear stress and stretch, extracellular pressure modifications, strains, variations of electric field in and around osteocytes lacunae. The osteocyte network, under physiological conditions, activates osteoclastogenesis and suppresses osteoblast function enhancing bone resorption and inhibiting bone formation. In the unloaded condition, the functions of the osteocyte network are augmented, whereas exercise could decrease inhibitory effects on bone mass by reducing both osteoclastogenesis and inhibition on osteoblast function.

Scientists have recently focused their attention on adult stem cells as new and more effective treatments for different diseases and disabilities. In fact, it is known that stem cells are capable of renewing themselves and that they can generate multiple cell types. Today, there is new evidence that stem cells are present in far more tissues and organs than once thought and that these cells are capable of developing into more kinds of cells than previously imagined. In this chapter, we focus the attention on teeth as source of stem cells. In particular, we describe the characteristic of the different types of dental stem cells and their use in tissue engineering.

Background: Osteoporosis is the most common skeletal disorder in the elderly, being characterized by impaired bone strength and increased risk of fracture. Severe osteoporosis is currently defined by the threshold of bone density value below the −2.5 SDS of T-score, determined by dualenergy X-ray absorptiometry, and the presence of one or more fragility fractures. This definition does not entirely reflect the spectrum of severity of the disease that provides a variable increase in fracture risk. Methods: This manuscript reports a consensus statement on the diagnostic criteria for severe osteoporosis in real-life clinical setting, achieved in an event held by Italian physicians with expertise in osteoporosis and metabolic bone diseases. Results: The group stated that a large number of fractures occur in subjects with T-score above −2.5. In light of recent advances on the structural basis of skeletal fragility, it became clear that bone density represents only one of the contributors to bone strength and number and severity of fragility fractures. The group suggests that the condition of two or more fragility fractures should be considered as severe osteoporosis, independently of bone density. Conclusions: The consensus statement proposes a more specific definition of severe osteoporosis, which should consider not only densitometric measurements, but also the number and severity of fragility fractures. Patients’ management and choice of treatment should take into consideration the type and severity of osteoporotic fractures, in addition to bone density.

Morton’s neuroma is a common injury of the forefoot that affects the third web space of the toes. The pain, localized to the forefoot and toes, may appear gradually but usually becomes significant and persistent. Often it occurs after walking and is relieved by removing the shoe and manipulating the forefoot. The management of this condition varies widely and includes conservative and surgical treatments. There is no general agreement on the optimal treatment for this pathology. The aim of this review was to collect and assess the scientific evidence reported in the literature supporting the different treatments in the management of Morton’s neuroma, comparing the different outcomes of conservative and surgical treatments. A literature analysis was performed on the different managements in the search for the best scientific evidence on this topic.

Twenty-four patients (37 feet, 51 toes) affected by hammertoe deformity of the lesser toes and treated surgically by arthrodesis of the proximal interphalangeal joint, stabilized with an intramedullary titanium cannulated screw, were reviewed 1–4 years after the operation. At follow-up, the arthrodesis was fused in 48 toes; three toes showed an asymptomatic radiographic nonunion, and in one of them the screw was broken. In seven toes, the cannulated screw was removed because of persistent pain at the tip of the toe where the head of the screw was located. In one case only, there was a late infection, with toe malalignment. All the patients were able to use street shoes 2 weeks after surgery. The average AOFAS score at follow-up was 86.54 points. Compared to the conventional temporary stabilization with an intramedullary Kirschner wire, the stabilization with a cannulated screw decreases the risk of infection, of radiographic nonunion, and of mallet toe deformity.

A 20-year-old man sustained an open medial dislocation of the ankle without an associated fracture after a low-energy inversion injury. Prompt debridement and reduction with primary wound closure of the skin were performed without suture of the capsule. Immobilisation in a non-weight-bearing cast for 30 days followed by ankle bracing for two weeks and subsequent physiotherapy, produced full functional recovery by three months. At follow-up at one year there was a full range of pain-free movement, although the radiographs and MR scan showed early post-traumatic degenerative change at the medial aspect of the tibiotalar and the calcaneocuboid joints.